Denial Prevention Specialist - CND Life Sciences

The Denial Prevention Specialist is responsible for working with the Back-End Billing specialist on denials and accounts receivables management for the department as defined by their manager. Duties include drafting written letters of appeal on various types of denied claims, contacting the insurance companies to follow up on unresolved appealed claims, aging AR, and additional projects as assigned.

Job Responsibilities:

• Conduct thorough account audits to ensure integrity and accuracy within the revenue cycle workflow
• Investigate payer denials related to referral, pre-authorization, eligibility/registration, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
• Prepare and submit tailored appeals to payers based on meticulous reviews of medical records, adhering to Medicare, Medicaid, and third-party guidelines, as well as internal policies, ensuring accuracy and timeliness. Contacts insurance companies to follow up on appealed claims. Holds insurance company accountable for timely resolution of all appeals submitted.
• Identify prevalent denial patterns and proactively communicate strategies to prevent future occurrences, offering education and guidance to stakeholders.
• Process and follow up on payer denials, rebilling, or submitting adjustments as needed.
• Manage outstanding AR related to denials.
• Create and manage systematic processing of denials according to departmental policy and performance standards.
• Manage correspondence and any medical records requests as defined within department workflow procedure to ensure timeless and accuracy of response.
• Respond to authorization denials by submitting retro-authorizations in compliance with payer requirements, facilitating efficient resolution.
• Complete special projects as assigned by Supervisor/Manager contributing to the continual improvement and effectiveness of revenue cycle operations.

Knowledge, Skills & Experience:

• 2-5 years of hands-on experience in medical billing with direct exposure to denials, appeals management, insurance
• Minimum 2+ years' experience in denial management required (experience with laboratory billing preferred)
• collections and related follow-up procedures.
• Demonstrated proficiency of the current ICD-10 and CPT coding system.
• Possess in-depth knowledge of Medicare, Medicaid, and commercial insurance.
• Possess a proficient understanding of Explanation of Benefits (EOBs) and a comprehensive grasp of remittance and remark codes, enabling accurate interpretation and resolution of payment discrepancies.
• Strong problem solving and analytics skills.
• Excel in multitasking, efficiently managing multiple tasks and priorities to meet deadlines and maintain workflow efficiency.
• Familiarity with diverse payer requirements for claims processing, ensuring compliance and optimizing reimbursement.
• Strong computer-based skills, specifically with Microsoft Word, Excel and PowerPoint, Salesforce, Medisoft and data analysis. Quadax.
• Possess strong communication skills, facilitating effective interaction with team members, stakeholders, and external parties to convey information clearly and collaborate efficiently.
• Experience with Salesforce, Waystar, TriZetto, and Quadax is a plus
• Knowledge of business processes, accounting principles, billing practices, medical terms, CPT, and ICD10 coding.

Education, Certifications & Licensures:

• High School diploma or equivalent required.

Other:

• This is a full-time remote opportunity in the PST or MST time zone.
• May require quarterly meetings in Phoenix lab headquarters or satellite Atlanta office.